Devastated family call for better post-operative care
Clinical Negligence News : 28 June 2012
The family of Ron Shute, a 74 year old man who died following a routine liver biopsy, have called for Weston General Hospital to improve its post-operative care.
Mr Shute suffered an abdominal hemorrhage on January 19th 2011 following his liver biopsy, which was described by Dr Christopher Cook, his surgeon, as being “extremely straight-forward, quick and free from complications”. The inquest at Flax Bourton Coroner's Court heard that Dr Cook carried out the biopsy having explained most of the risks to Mr Shute.
The UK mortality rate following a biopsy is estimated by medical literature at being roughly 1 in 1,000.
Mr Shute was taken back to his ward after the biopsy at 3pm, but his condition began to deteriorate. At 4.45pm, nurses raised concerns but found Mr Shute’s vitals to be ‘stable’. At 7.35pm, consultant surgeon Dr West came to see Mr Shute and decided that he wanted the patient to be operated on. However, due to the shortage of theatre space on the busy night, this was not possible. Mr Shute suffered a heart attack at 8pm and could not be resuscitated. Mr West stated after the death that even if the surgery had taken place, Mr Shute would have been unlikely to survive.
An inquest into Mr Shute’s death found there to be no neglect, nor malpractice by medical staff. Despite this verdict, Mr Shute's family still feel that his death could have been prevented.
The retired personnel manager had been fit and healthy until 2009 but in 2010 was diagnosed with a low grade lymphoma following a heart valve operation. After his health deteriorated and his liver had become enlarged, Mr Shute was booked in for a biopsy on to see if the cancer had spread.
Deputy Avon coroner Terrence Moore passed a narrative verdict: "Mr Ronald Shute died as a result of a rare but recognisable complication of a liver biopsy, which was performed following a significant deterioration in his condition, to investigate the possibility of a progression of the lymphoma from which he suffered."
Mr Shute’s son, Gary, said “We had been told the biopsy would be straightforward and dad would be out of hospital the same day, but when he was on the recovery ward he said to my mum he was bleeding where the sample had been taken and was very shivery”
“His blood pressure was very low and the nurses began talking about not having enough experience to cope with him. A doctor was called but he took nearly half an hour to arrive and as soon as he took a blood sample, dad started losing consciousness and the monitoring machines started urgently beeping”
“We were never told the biopsy could be fatal and there seemed to be no sense of urgency when he began suffering problems. We believe dad would still be alive if medical staff had called for senior assistance sooner, who would have treated him appropriately. We know nothing will bring dad back but we hope the hospital improve the standards of their post-operative care so no one else has to go through what we have.”
A Weston Area NHS Trust spokesman expressed sympathy for Mr Shute’s family, stating, "The trust accepts the coroner's verdict and repeats the condolences to Mr Shute's family."